Duodenal perforations after laparoscopic cholecystectomy.

Duodenal perforations after laparoscopic cholecystectomies are rarely reported. The aim of this study is to focus on this complication and to suggest ways to reduce its occurrence and avoid diagnostic mistakes and therapeutical delays that could be fatal. We reviewed four personal cases and a number of others reported in the literature. Duodenal perforations are caused by improper use of the irrigator-aspirator device when retracting the duodenum, or by electrosurgical and laser burns. A duodenal perforation should be suspected in cases of bile leakage, peritonitis, intraabdominal or retroperitoneal collections, high serum or drainage amylase concentration, absence of bile leakage from the biliary tree, and the existence of a retroduodenal mass. Diagnosis requires a gastrografin upper GI series. Differential diagnosis is mainly with biliary lesions and other causes of peritonitis. Relaparoscopy may require intraoperative upper GI endoscopy or Kocher's duodenal mobilization to detect the perforation. Early diagnosis allows primary repair, usually by laparoscopy. Perforations of the duodenal cap are easier to diagnose and have a better prognosis than those of the descending duodenum. A lumbar abscess is a frequent complication.

Gasless laparoscopic resection of hepatocellular carcinoma (HCC) in cirrhosis.

Liver resection by open surgery remains the method of choice for treatment of hepatocellular carcinoma (HCC) in cirrhotic patients with compensated liver function. Laparoscopy for surgical treatment of hepatic diseases is at an early stage. Laparoscopy has been often proposed for diagnosis, staging of hepatic malignancy, treatment of hepatic cyst or benign tumors, but very few laparoscopic treatments of hepatic malignancies have been reported at present and always using conventional CO2 laparoscopy. We describe herein the operative treatment of a single subglissonian HCC of segment III in a child, HCV (hepatitis C virus)-related cirrhosis. A nonanatomical wedge resection was performed by gasless laparoscopic technique using a mechanical retractor obviating the creation of the pneumoperitoneum and of the sealed environment. The technique, in selected cases, is a simple, safe, and effective surgical method. The gasless technique guarantees a clear vision, it makes possible the continuous suction of smoke and fluids, it allows the use of conventional instruments for classic maneuvers of the liver surgery (Pringle maneuver), and the easy management of suturing. The present case has proved to be another abdominal procedure that can be carried out with all the advantages of gasless minimally invasive surgery.